Provider Demographics
NPI:1750861274
Name:LEACH, SUSANNAH LEE (RD, LD)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:LEE
Last Name:LEACH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 CIMARRON PKWY
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-6859
Mailing Address - Country:US
Mailing Address - Phone:770-639-9529
Mailing Address - Fax:
Practice Address - Street 1:1420 CIMARRON PKWY
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-6859
Practice Address - Country:US
Practice Address - Phone:770-639-9529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004757133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered